Nurses Contact & Health Forms

HEALTH SERVICES DEPARTMENT

Cardinal

"Cultivating whole-student wellness through quality care and community connections"

815.645.2230

Name Building Extension
Kayla McKinney, RN Director & SVHS 5008
Carrie Boehle, RN Monroe Center 3362
Aaron Christianson, RN Highland 2102

General District Health Forms

M223 Emergency Health Information Form

M223 Emergency Health Information Form (Spanish)

District Health Requirements Letter to Parents

State of IL School Physical Form

State of IL School Dental Exam Form

State of IL School Eye Exam Form

Authorization for Administration of Medication Permit


Waivers

*Not necessary unless any of the exam forms above are incomplete*

State of IL Certificate of Religious Exemption

State of IL School Dental Exam Waiver Form

State of IL School Eye Exam Waiver Form


Required Annual Forms for Health Conditions

Asthma

Asthma Action Plan

Authorization for Administration of Medication Permit

Individualized Healthcare Plan (IHP) written by school nurse

Diabetes

Diabetes Medical Management Plan (DMMP) provided from physician

Hypoglycemia Emergency Action Plan

Hyperglycemia Emergency Action Plan

Authorization for Administration of Medication Permit

Individualized Healthcare Plan (IHP) written by school nurse

Food Allergy

Food Allergy & Anaphylaxis Emergency Action Plan

Authorization for Administration of Medication Permit

Individualized Healthcare Plan (IHP) written by school nurse

Insect Sting Allergy

Anaphylaxis Emergency Action Plan

Authorization for Administration of Medication Permit

Individualized Healthcare Plan (IHP) written by school nurse

Seizures

Seizure Action Plan

Authorization for Administration of Medication Permit

Individualized Healthcare Plan (IHP) written by school nurse

Health Forms by Grade Level

Every Grade

M223 Emergency Health Information Form or

M223 Emergency Health Information Form (Spanish)

Pre-K

State of IL School Physical Form

Kindergarten

State of IL School Physical Form

State of IL School Dental Exam Form

State of IL School Eye Exam Form

2nd Grade

State of IL School Dental Exam Form

6th Grade

State of IL School Physical Form

State of IL School Dental Exam Form

9th Grade

State of IL School Physical Form

State of IL School Dental Exam Form

12th Grade

Up-to-Date Vaccination Record with proof of vaccination against meningitis

If you have any questions regarding which forms are needed, please contact your student's school nurse or Kayla McKinney, Director of Health Services at kmckinney@mail.meridian223.org.